In 2003, the President’s Emergency Plan for AIDS Relief was launched under two different, yet incredibly interdependent, concepts.
The first lies in the context of the time. In 2003, the world was not even two years away from the catastrophic and earth-shattering events of 9/11. Leaders across the United States recognized that what happens abroad matters here at home, and promoting the health, safety and stability of communities across the globe has a net benefit for American peace and prosperity. As Elizabeth Kennedy Trudeau, Bradford M. Freeman Managing Director for Global Policy at the George W. Bush Institute, recently shared, Americans continue to see the benefit of global partnership every time they fly, receive goods, or trust a financial system.
The second concept behind PEPFAR comes from the inherent values that have been America’s foundation for the last 250 years – faith, compassion, and opportunity. PEPFAR is a shining example of these values and was created with the understanding that to whom much is given, much is required.
Balancing these concepts of domestic interest and humanitarian compassion led to PEPFAR’s success. It has saved over 26 million lives, created a network of faith-based clinics providing care for millions, and enabled babies born HIV-free to grow into successful adults. At the same time, an epidemic has been contained, and spillover effects like growing economies with new markets on the African continent have made Americans safer and more prosperous.
Today, bilateral health agreements under the America First Global Health Strategy emphasize a transition to foreign investment that is comprehensive across diseases rather than limited to a specific threat like HIV. As I recently share in a new project, integration of health systems and services amplifies U.S. global health investment. As the Department of State undertakes this transition, the United States must continue to nurture the compassion-driven relationships and outcomes that are the foundation of PEPFAR, and not put decades of trust and partnership and millions of lives at risk.
To read more about our new project, see the Bush Institute Insights section below.
Bush Institute Insights
Economic and political challenges have impacted countries’ ability to support their own health systems. The United States, international implementers, and multilateral organizations have made life-saving investments in combating specific deadly diseases. As foreign assistance evolves, translating the impact of these disease-specific efforts into cost-effective, integrated, collaborative solutions is the next challenge to ensure sustained success.
The United States and other bilateral partners have inadvertently contributed to a system where foreign investment is disease-specific (known as a “vertical” model) rather than comprehensive across health systems (known as a “horizontal” model). This makes it difficult to invest across disease areas. Over time, this has created duplication, putting more of a strain on U.S. funding.
My latest piece, “One System, Greater Impact: How integrating health systems and services amplifies U.S. global health investment”, analyzes the obstacles posed to beneficiaries throughout every step of their health journey – including testing, treatment, monitoring, and financing. It then outlines several considerations that are necessary to de-silo and integrate health systems and services into primary health care. These methods will help ensure that beneficiaries of U.S.-supported programming have healthy babies, that they have more time and resources to contribute to growing economies, and that their country governments foster better use of taxpayer dollars.
As the new U.S. global health strategy shifts to support cost-effective, patient-centered, and country-owned platforms, clear metrics, breaking down barriers, and using communities to meet beneficiaries’ needs are required to ensure sustained outcomes and impact of current programming.
Figure of the Week
72% of Americans support U.S. funding to fight infections diseases globally
A ONE survey of more than 8,000 U.S. adults finds strong, growing bipartisan support for global health investments. By a more than 7 to 1 margin, Americans support investments in preventing and treating diseases in other countries to reduce the risk of future outbreaks reaching the U.S.
Support has increased from 65% in 2025 to 72% in 2026. Across party lines, 65% of self-identified Republican voters and 86% of Democratic voters support continued global disease investments. Public support is even higher for HIV/AIDS programs, with 79% of Americans favoring U.S. investment in global HIV treatment.
Ally Updates
Many people living with HIV and/or tuberculosis (TB) face increased risk of comorbidities, or co-infections, like cervical and anorectal cancers, depression, anxiety, and substance use conditions. For example, women living with HIV are six-times more likely to develop cervical cancer (a preventable cancer) than their HIV-negative counterparts. At the Bush Institute, we work alongside UNAIDS and PEPFAR through the Go Further partnership to screen and treat women living with HIV for precancerous lesions in the highest burden countries. Since 2018, the program has conducted 10 million screenings. Countries should learn from Go Further and invest in health care programs that fight HIV while mitigating co-occurring conditions.
UNAIDS and the United for Global Mental Health reviewed and mapped Global Fund investments in Grant Cycle 7 that integrate HIV- and TB-related comorbidities into HIV and TB programs and primary health care. The report shows that this approach is already taking hold: Among 103 countries reviewed, 97% included at least one priority comorbidity in their funding requests. This shows a strong focus on integrating comorbidities into country commitments and Global Fund investments through person-centered care. As countries begin drafting the implementation plans for their bilateral health agreements with the United States, they must continue to prioritize these integrations into primary health care.
While close to $550 million in investments targeted priority comorbidities, most requests exceeded available resources, highlighting persistent financing gaps and the need for integrated, person-centered health services.
In the News
- A Think Global Health interactive analysis examines bilateral health agreements signed under the America First Global Health Strategy and finds wide variation in countries’ cofinancing commitments and capacity to sustain health investments. On average, partner governments are expected to finance about 37% of the agreements’ total cost. However, Think Global Health warns that some countries could face declining overall health budgets if U.S. financing decreases faster than domestic spending increases, as is projected for some countries. As of March 13, the U.S. has signed 26 agreements governing spending between 2026 and 2030 totaling nearly $20 billion, according to the KFF interactive tracker.
- The U.S. Department of State has launched a new grant platform that provides up to $4.5 billion to support global health projects aligned with bilateral health agreements. The “Advancing Global Health” program invites international and local nongovernmental organizations, faith-based organizations, universities, companies, and government entities to propose projects that complement government-to-government health partnerships. Awards may range from $500,000 to $250 million and support projects lasting up to five years. Initial priority areas include strengthening child protection systems and supporting rapid outbreak response to detect and contain emerging infectious diseases. However, it is unclear what accountability mechanisms will be put in place and who will oversee these grants. Congress and the Department of State must work together to ensure that these grants meet the goals and targets of disease threats, that they are informed by disaggregated data and metrics, and that grantees are held accountable to achieve tangible results.
- In a Foreign Affairs analysis, Landry Signé, Professor and Executive Director of the Washington Center at Arizona State University, writes that while experts have predicted that African countries will experience economic catastrophe as a result of declines in foreign investment, the foreign investment cuts have actually showcased the continent’s structural resilience. Drawing on UN data, Signé reveals that 61% of African countries are either relatively insulated from shocks like foreign investment cuts or possess the institutional capacity to absorb them, or have both advantages. In response to reductions in U.S. and European investment, several African governments mobilized domestic resources, raised capital on international markets, and diversified trade partnerships. Signé concludes that policymakers should recalibrate risk assessments and tailor engagement in the continent to strengthen governance, regional integration, and long-term economic growth.
- New York Times journalist Stephanie Nolen published a piece on March 16 which details an alleged internal memo from the Department of State outlining conditions for Zambia to receive $1 billion in U.S. global health investment over five years. The conditions reportedly include a domestic commitment of $340 million in health spending by the Zambian government, an agreement for Zambia to give American businesses more access to its rich minerals deposits, and a renegotiation of a contract with the Millennium Challenge Corporation to require regulatory changes in mining and other industries.
- In Okrika, a fishing community in Rivers State, Nigeria, health workers are helping to prevent mother-to-child HIV transmission and connect infants to health care by combining antenatal education, mentor mother support, and same-day early infant diagnosis using GeneXpert technology. At one facility, staff increased early infant testing from 0% to 100% within a month by tracking patients, sending text reminders, and conducting home visits in hard-to-reach fishing communities. They also identified babies born to mothers living with HIV who had never been tested and brought them to the facility for screening. Rivers State has the highest estimated number of children living with HIV in Nigeria. Still, the babies at Okrika represent hope for eliminating HIV in this community, says Dr. Umahi at the Elizabeth Glaser Pediatric AIDS Foundation.
- Malaria No More released a new report, “Force Protection At Risk,” that examines the Department of Defense’s (DoD) malaria-prevention strategy and outlines how resistance to insecticides and antimalarial drugs increases the likelihood of breakthrough infections among U.S. service members deployed to endemic regions. The report recommends that Congress and the DoD renew investments in malaria prevention to protect U.S. troops, reinforce public health benefits, and continue U.S. leadership in infectious disease research.
- Recent commentary in the Journal of the International AIDS Society notes that the future of HIV response will depend on countries’ ability to integrate HIV services into broader health systems. While new HIV infections have declined in many regions, the epidemic remains deeply entrenched, particularly among adolescent girls and young women. The authors call for locally led governance, diversified and sustainable financing, and stronger community engagement to protect vulnerable populations. As innovations such as long-acting prevention tools and digital health platforms expand, the paper emphasizes that thoughtful integration grounded in equity and accountability will be critical to sustaining progress and building more resilient health systems.
